Covid-19 - Vulnerable Highest Risk Patients (Shielding)

People in the Clinically Extremely Vulnerable Group (CEV) 

The government has confirmed that from 1st April 2021, shielding advice will be paused nationally. In summary, the new advice from the 1 April 21 is to continue to work from home where possible and if individuals cannot work from home, employers should undertake a comprehensive, individual, workplace risk assessment reflecting the current working context (ie improved testing, vaccination and relationship with transmission). Government guidance on protecting those that are clinically extremely vulnerable can be found here.

The Government will write to all CEV individuals in England as necessary to inform them of the updated guidance and the steps people can take to reduce their risk. Copies of the letters sent to patients are published here.

NHSE will nationally continue to update the Shielded Patient List (SPL), so it is important that practices continue to add and remove patients (as appropriate), as it may be necessary to identify this cohort in the future. Details on how to add and remove people from the SPL are available in full on  NHS Digital’s website.

Identifying the Clinically Extremely Vulnerable (CEV)

The government updated the definition of the clinically extremely vulnerable group on 16th February 2021.

There are now 3 ways for a patient to be identified as clinically extremely vulnerable:

1. They have one or more of the conditions listed below.
2. Their clinician or GP has added them to the Shielded Patient List because, based on their clinical judgement, they deem the patient to be at high risk of serious illness if they catch the virus.
3. The patient has been identified through the  COVID-19 Population Risk Assessment  as potentially being at high risk of serious illness if they catch the virus. NHS Digital now host an online clinical risk assesment tool powered by QCovid® which helps clinicians better understand how at-risk a person may be of catching coronavirus and being admitted to hospital or catching coronavirus and dying. GPs were sent a letter on 15th February 2021 detailing how additional people have been identified through this method and added to the shielding list by NHS Digital. It also includes a Q&A around this. There are some instructions for individuals and organisations to follow before using the tool, including the requirement for a Data Protection Impact Assessment (DPIA) and privacy notice in place that covers the tool’s use. A template DPIA and privacy notice have been provided to support you to do this.

Following the population risk assessment there was concern about some patients who had been identified as potentially high risk due to previous gestational diabetes. NHS Digital have updated their guidance to support clinicians whose patients with previous gestational diabetes have been advised to shield via the QCovid process. This is supported by a gestational diabetes flowchart developed by the Royal College of General Practitioners.

 

• Solid organ transplant recipients.
• People with specific cancers:
• people with cancer who are undergoing active chemotherapy
• people with lung cancer who are undergoing radical radiotherapy
• people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
• people having immunotherapy or other continuing antibody treatments for cancer
• people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
• people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
• People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary (COPD).
• People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as Severe combined immunodeficiency (SCID), homozygous sickle cell).
• People on immunosuppression therapies sufficient to significantly increase risk of infection.
• Women who are pregnant with significant heart disease, congenital or acquired.

On 2nd November, NHSE & I sent an update on guidance for clinically extremely vulnerable individuals and actions for GPs. 

Two additional groups of people have been identified who should now be considered as clinically extremely vulnerable to COVID-19: -

• adults with stage 5 chronic kidney disease 
• adults with Down’s syndrome 

Practices are being asked to: -

Familiarise themselves with any updated guidance for clinically extremely vulnerable people when it is published here. 

Publication will be communicated to all patients on the shielded patient list (SPL) by letters. These letters will provide evidence for Statutory Sick Pay purposes if required. NHSE will seek to provide primary care with any additional information following that publication here. Seperate letters have been sent to children and young people who are clinically extremely vulnerable.

Review any children and young people remaining on the SPL who your practice added and, where appropriate, remove them from the SPL. Practices should also plan to urgently respond to calls from parents and guardians of children on the SPL seeking a review – parents and guardians will be advised by Government to contact their child’s specialist or their GP, if they are still unsure whether their child should remain on the SPL (Annex 1).

a. NHSE want to highlight that the vast majority of children and young people who have been reviewed to date using the Royal College of Paediatrics and Child Health ( RCPCH ) guidance have been found to be no longer considered clinically extremely vulnerable. Given the detrimental impact to children’s wellbeing of following unnecessary additional restrictions, it is important we complete this exercise as soon as possible.

Continue to maintain the SPL by adding a high risk flag for patients you identify as being clinically extremely vulnerable, and notifying the patient of their status and the advice they should follow. Information on maintaining the SPL can be found on the NHS Digital website. NHSE have previously published best practice guidance on providing NHS care for those who shielded during the initial wave of COVID (see Annex B in 4 June letter ).

NHS Digital useful resource pages 

• Shielded Patient List: guidance for General Practice
• The Shielded Patient List and how it works
• How to flag high risk patients (includes template letter to send to patient)
• Covid-19 Population Risk Assessment
• Covid-19 Clinical Risk Assessment Tool

Support will remain available to the CEV group from NHS volunteers and practices can make a referral at  https://www.goodsamapp.org/NHSreferral

Children

16^th Nov 2020 – NHSE have produced a document entitled Reviewing and removing children and young people from the Shielded Patient List Instructions for clinicians and data leads. This is to aid conversations and the decision processes and has guidance specific for GP’s on Pages 7 & 8. Click on the image to download your copy.

Further guidance was published in 8th July confirming that the majority currently considered extremely vulnerable to Covid-19 would be able to be removed from the shielded patient list. The guidance can be viewed here .

Adults with Downs Syndrome have been added to the Clicically extremely vulnerable list, however, the RCGP have made the following staement about children with Down's Syndrome

There is evidence that some adults with Down’s syndrome may be at risk of complications from COVI-19, this primarily appears to be age related. There is no evidence that children with Downs syndrome and without co-morbidities need to take more care than is currently advised for all. Some children with Downs syndrome will have co-morbidities from either Group A or Group B, and they and their families will need to have conversations with their clinicians to determine if they are clinically extremely vulnerable. More information is available from the  Down’s Syndrome Association. 

The Royal College of Paediatrics and Child Health

Covid-19 – shielding advice for children and young people

Summary

The RCPH has updated its advice for clinicians on which paediatric patient groups should be advised to 'shield' during the COVID-19 outbreak, to protect those at very high risk of severe illness from coming into contact with the virus. It also provides frequently asked questions on how 'shielding' applies to children and families. We would recommend that you refer to the detailed guidance for comprehensive advice, however, the following provides a summary of some of the key points.

In updating their advice, the RCPH has conducted a review of the evidence which has indicated that not all those children and young people who are currently advised to shield need to continue to do so. The majority of children with conditions including asthma, diabetes, epilepsy, and kidney disease do not need to continue to shield and can, for example, return to school as they reopen. This includes many children with conditions such as cerebral palsy and scoliosis, for whom the benefits of school - in terms of access to therapies and developmental support - far outweigh the risk of infection.

In principle:

• Children and young people who are cared for just in primary care are very unlikely to need to continue to shield.
• A small group of children who are ‘clinically extremely vulnerable’ due to their pre-existing condition will need to continue to shield.
• A further larger group of children exists who due to their underlying condition may need to shield and the decision to continue to shield would normally result from a discussion between the clinician, the child and their family

In the document, conditions are divided into two groups, as follows:

• Group A lists conditions that require continued shielding. A child with a condition in Group A should be advised to shield.
• Group B lists conditions that require discussion between the clinician and the child and their family/carer to establish whether on a case by case basis continued shielding is required. A child in Group B should have a discussion with their clinical team to establish whether on balance of risks they should be advised to shield. Not all children and young people with conditions listed in Group B will need to shield. If following a discussion, they are advised not to shield, the child should maintain stringent social distancing.

Group A includes:

• Immunodeficiency and immunosuppression
• Oncology

Group B includes:

Conditions listed in the categories below will require a case-by-case discussion to decide whether, on the balance of risks, a child should be advised to continue shield. Not all children and young people in the categories listed below will need to shield.

A decision to shield will depend on the severity of the condition and knowledge that the secondary and tertiary care clinical teams have of the particular circumstances of the child. If following a discussion, a child is advised not to shield, they should maintain stringent social distancing.

• Cardiology
• Dermatology
• Haematology
• Immunodeficiency
• Neonatal
• Neurology
• Paediatric Gastroenterology, Hepatology & Nutrition
• Respiratory
• Renal
• Rheumatology / Paediatric ophthalmology

Children who are shielded should still attend hospital for essential treatment as recommended by their clinical teams, following risk assessment.

The RCPH advice reflects the current understanding of the risks associated with COVID-19 infection. Their advice will continue to be updated and revised more is understood about the impact of COVID-19 infection on the health of children and young people with comorbidities. It is therefore important to refer to the full guidance at https://www.rcpch.ac.uk/resources/covid-19-shielding-guidance-children-young-people#introduction .